Ramblings of an Emergency Physician in Texas

Archives for February 25, 2010

It’s been a while since I’ve attended a conventional medical Grand Rounds. These were events where a medical luminary would fly in to give a medical audience a state-of-the-art presentation on a medical subject. Ideally, the speaker was a thought leader and a researcher on the issue.

These presentations were usually not a demonstration of the virtue of humility. We physicians, as a class, have generous egos. Academic physicians occupy a higher rung on the ego ladder. Medical Grand Rounders (MGRs), who are on the GR speaking circuit, often must bring their own ladders to assure they will be able to reach their desired atmospheric height.

Welcome to the American Board of Emergency Medicine (ABEM) public website. ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS). ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards. ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization. For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam. Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination. Okay, I’m done, right?
Emmm, no. I’m BC for 10 years. In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM. Which ABEM didn’t bother to figure out how to give us CME credit for. Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance. In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s. I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified? Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par? Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea. That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible. Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm. I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM. ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy. Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies. But, you had to give the currently wrong answer to the test. Pitfalls of keeping up through testing.